Haptic augmented and virtual reality system for simulation of surgical procedures

ABSTRACT

The present technology relates to systems, methods and devices for haptically-enabled virtual reality simulation of cerebral aneurysm clipping, wherein a user uses two physical stations during the simulation. The first station is a haptic and augmented reality station, and the second station is a haptic and virtual reality station.

RELATED APPLICATIONS

This is a continuation of U.S. application Ser. No. 15/389,841 filedDec. 23, 2016, which is a continuation-in-part of U.S. application Ser.No. 13/628,841, filed on Sep. 27, 2012, now U.S. Pat. No. 9,563,266. Theabove-mentioned applications are hereby incorporated by reference hereinin their entirety.

FIELD OF THE INVENTION

The present technology relates to methods, devices and systems forhaptically-enabled simulation of cerebral aneurysm clipping using ahaptic augmented and virtual reality system that includes an opensurgery station that simulates performance of open surgery steps and amicrosurgery station for simulates performance of microsurgery steps.

DESCRIPTION OF RELATED ART

Brain aneurysms are associated with a very significant mortality andmorbidity related to stroke in previously healthy young patients, aswell as older patients. Aneurysm clipping is an important procedure forlarge and complex aneurysms which cannot be treated by aneurysm coilingmethods. Additionally, regardless of the complexity of the aneurysmitself, it regularly takes medical residents up to six months just tolearn how to approach the aneurysm location surgically by pterionalcraniotomy and Sylvian fissure dissection. Moreover, in studyingsurgical methods of aneurysm clipping, there are also many elements ofsurgical judgment to be learned, such as optimal operative angle fromwhich to approach the aneurysm, which affects craniotomy placement.

BRIEF DESCRIPTION OF THE DRAWINGS

Specific examples have been chosen for purposes of illustration anddescription, and are shown in the accompanying drawings, forming a partof the specification.

FIG. 1 illustrates a perspective schematic view of one example of aknown open surgery station, which can be used in a haptic augmented andvirtual reality system of the present technology.

FIG. 2 illustrates a block diagram of a known software and hardwarearchitecture for the system of FIG. 1.

FIG. 3 illustrates a second perspective schematic view of the opensurgery station of FIG. 1.

FIG. 4 illustrates a perspective schematic view of one example of amicrosurgery station of the present technology, which can be used in ahaptic augmented and virtual reality system of the present technology.

FIG. 5 illustrates a block diagram of one example of a method ofperforming simulated cerebral aneurysm clipping with a haptic augmentedand virtual reality system of the present technology.

FIG. 6 illustrates one example of a haptic stylus that can be used in ahaptic augmented and virtual reality system of the present technology.

FIG. 7 illustrates one example of a virtual aneurysm clip that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 8 illustrates one example of a virtual aneurysm clip holder thatcan be provided in an instrument library in a haptic augmented andvirtual reality system of the present technology.

FIG. 9 illustrates one example of a virtual craniotome that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 10 illustrates one example of a virtual suction tip 69 that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 11 illustrates one example of a virtual burr tool 64 that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 12 illustrates one example of a virtual cauterizer that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 13 illustrates one example of a virtual bipolar electrocauteryforceps that can be provided in an instrument library in a hapticaugmented and virtual reality system of the present technology.

FIG. 14 illustrates one example of a virtual surgical marker that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 15 illustrates one example of a virtual screw that can be providedin an instrument library in a haptic augmented and virtual realitysystem of the present technology.

FIG. 16A illustrates one example of a virtual acorn drill bit that canbe provided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 16B illustrates one example of a virtual spherical drill bit thatcan be provided in an instrument library in a haptic augmented andvirtual reality system of the present technology.

FIG. 17 illustrates one example of a virtual reciprocating saw that canbe provided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 18 illustrates one example of a virtual microscissors that can beprovided in an instrument library in a haptic augmented and virtualreality system of the present technology.

FIG. 19 illustrates one example of a simulated radiology scan of apatient displayed by an open surgery station of FIG. 1.

FIG. 20 illustrates one example of a 3D model of a skull displayed by anopen surgery station of FIG. 1.

FIG. 21 illustrates the 3D model of a skull of FIG. 20, with a bone flapremoved.

DETAILED DESCRIPTION

The present technology includes haptic augmented and virtual realitymethods, systems and devices for performing simulated surgicalprocedures that include open surgery steps and microsurgery steps,including but not limited to cerebral aneurysm clipping.

Simulation methods of the present technology for cerebral aneurysmclipping can include all aspects of an aneurysm surgical procedure,including, for example, craniotomy, dural opening, dissection of theSylvian fissure, clipping of an MCA (middle cerebral artery) bifurcationaneurysm, and flow testing of the patency of the parent vessel. Themethods, devices, and systems of the present technology can be used withcomprehensive surgery simulation systems that use both an open surgerystation and a microsurgery station so as to simulate both open views ofvirtual patient anatomy and microscopic views of virtual patientanatomy.

As used herein, the term “open surgery station” should be understood tomean that an environment is provided in which the visual displayprovided to a user includes virtual reality aspects superimposed overreal reality, and in which a user can see aspects of real reality inaddition to the superimposed virtual reality aspects while performingsteps of simulated open surgery. For example, at an open surgerystation, a user can interact with displayed virtual patient anatomy, anda simulated surgical instrument can be displayed in a manner that itappears to be held in the actual hand of a user holding a haptic stylusas a proxy for the instrument.

As used herein, the term “microsurgery station” should be understood tomean that an environment is provided in which the visual displayprovided to a user consists of virtual aspects, which are computergenerated graphics, that the user can see while performing steps ofsimulated microsurgery. For example, at a microsurgery station, a usercan interact with displayed virtual patient anatomy using displayedvirtual surgical instruments, and although the user uses a haptic stylusas a proxy for the instrument, the user does not see aspects of realreality.

Haptic Augmented and Virtual Reality Systems

As discussed above, haptic augmented and virtual reality systems of thepresent technology can include an open surgery station 10 that simulatesopen surgery, one example of which is illustrated in FIGS. 1 and 3, anda microsurgery station 11 that simulates microsurgery, one example ofwhich is illustrated in FIG. 4. Stations 10 and 11 can both include someof the same types of physical components, and for ease of reference likephysical components are labeled with like reference numbers for bothstations 10 and 11 in FIGS. 1-5.

Some examples of open surgery stations that can be used in the presenttechnology are described in U.S. Pat. No. 7,812,815, which is herebyincorporated by reference in its entirety. With reference to the opensurgery station 10 for simulating open surgical steps, the user 12 cansit or stand at a physical desktop workspace 14 defined by a housing 16that has an opening 18 on one side. The open surgery station 10 caninclude a multi-sensorial computer interface that includes astereoscopic vision interface 20, at least one haptic device 22, and a3D sound system 24. Additionally, a head tracking device 26 and a handtracking device in the form of at least one haptic robot stylus 27 canprovide information regarding the user's interaction with the system aswell as the user's visual perspective relating to the open surgerystation 10.

With reference to the microsurgery station 11 for simulatingmicrosurgical steps, the user (not shown in FIG. 4) can sit or stand ata physical desktop workspace 14 defined by a housing 16 that has anopening 18 on one side. The microsurgery station 11 can include amulti-sensorial computer interface that includes a binocular surgicalmicroscopic eyepiece 31, at least one haptic device 22, and a 3D soundsystem 24. Additionally, a hand tracking device in the form of at leastone haptic robot stylus 27 can provide information regarding the user'sinteraction with the system as well as the user's visual perspectiverelating to the microsurgery station 11.

Surgical procedures that can be simulated using haptic augmented andvirtual reality systems of the present technology can include proceduresthat use a one-handed technique, or that require use of multiple hands.Accordingly, the open surgery station 10 and the microsurgery station 11can each include at least one, or two, haptic devices 22, which trackthe user's hand position and orientation and provide force feedback tothe user. For example, since many parts of aneurysm clipping procedurestend to require a two-handed technique, the methods of aneurysm clippingsimulation provided herein can include the simultaneous use of twohaptic devices 22. A 3D image of a first surgical tool can be collocatedwith a first haptic device 22, and an image of a second surgical toolcan be collocated with a second haptic device 22. For example, thesimulation method can include a user holding a first haptic device 22 ina first hand, such as the right hand, and superimposing an image of afirst surgical tool, such as an aneurysm clip holder or an arachnoidknife over the first haptic device 22. The simulation method can alsoinclude a user holding a second haptic device 22 in a second hand, suchas the left hand, and superimposing an image of a second surgical tool,such as a suction tip over the second haptic device 22. Other surgicaltools can also be simulated, such as a bipolar electrocautery tip,microscissors, and other instruments, as appropriate.

The open surgery station 10 and the microsurgery station 11 can eachinclude a display system that allows the user to acquire depthperception. Each display system can be driven by graphics logic, whichcan control and update the graphics displayed by the display system. Thedisplay system of the open surgery station 10 can use a display screen28 that can be a single passive stereo monitor, a half-silvered mirror30 to reflect the image of the display screen 28, and a head trackingsystem 26 to display a dynamic viewer-centered perspective. Thepartially transparent mirror 30 can permit the user 12 to see both thevirtual reality display and the user's hands, thus providing anaugmented reality environment. The user can hold and manipulate thehaptic device 22 with its stylus 27 below the mirror 30. The displaysystem of the microsurgery station 11 can display a static perspectiveby using two display screens 28, which can be non-stereo monitorslocated side by side and a binocular surgical eyepiece 31, which canconsist of four first-surface mirrors oriented at an angle in such a waythat the image of the left monitor is only seen by the left eye, and theimage of the right monitor is only seen by the right eye. Theorientation and distance between the front-surface mirrors can beadjusted by the user to match his/her interocular distance.

In the open surgery station 10, a virtual projection plane can belocated exactly at the center of the haptic workspace and orientedperpendicular to that line, whereas in the microsurgery station 11 theuser can view the virtual projection through the binocular surgicalmicroscopic eyepiece 31. In the open surgery station 10 the partiallytransparent mirror 30 can preferably be sufficiently wide to allow theuser to view virtual objects from different viewpoints (displaying thecorrect viewer-centered perspective) while permitting a comfortablerange of movement. In contrast, in the microsurgery station 11, thebinocular surgical microscopic eyepiece 31 can be adjusted up or down,either manually or by an automatic up-down adjustor, and the interoculardistance can also be adjusted for comfortable 3-dimensional viewing. Inone example, the height of the binocular surgical microscopic eyepiece31 can be adjusted by adjusting the eyepiece mounting frame 33 can beadjusted up or down by activating a first foot pedal 34 or by a handswitch 35 on housing 16. In some examples, one or more additional footpedals 34 can be provided to activate certain simulated surgicalinstruments such as a bipolar electrocautery forceps 68 as discussedbelow with reference to FIG. 5.

The computer 32 illustrated in FIG. 3 can be operatively connected toboth the open surgery station 10 and the microsurgery station 11.Alternatively, the open surgery station 10 and the microsurgery station11 can each be operatively connected to a separate computer 32, and inone example the separate computers can be linked via a wireless or wirednetwork connection. The one or more computers can be components of ahaptic augmented and virtual reality system that includes open surgerystation logic that controls and operates the open surgery station 10,and microsurgery station logic that controls and operates themicro-surgery station 11. The haptic augmented and virtual realitysystem can include a software library that provides, in real time, ahigh level layer that encapsulates the rendering of a scene graph oneither display screen 28, the stereoscopic vision interface 20, thehandling of the hand tracking device shown as a haptic robot stylus 27,an interface with a haptic device 22, and playback of 3D spatial audioon a 3D sound system 24.

With respect to the open surgery station 10, a computer 32 can includehaptics rendering logic that drives each haptic device of the opensurgery station 10, and graphics logic that drives the display system ofthe open surgery station 10. The computer 32 connected to the opensurgery station 10 can also include open surgery station logic, whichcan integrate the haptics rendering logic and the graphics logic andprovide real-time simulation of open surgery steps of a surgicalprocedure, including updating the open surgical views in real time inresponse to user operations performed with a haptic device of the opensurgery station 10. The open surgery station logic can also include aninstrument library that includes a plurality of virtual surgicalinstruments that can each be selected by a user and displayed by thedisplay system of the open surgery station 10. Some examples ofinstruments that can be included in the instrument library for use withthe open surgery station 10 are discussed below with respect to the opensurgery steps of the aneurysm clipping methodology.

With respect to the micro-surgery station 11, a computer 32 can includehaptics rendering logic that drives each haptic device of themicro-surgery station 11, and graphics logic that drives the displaysystem of the micro-surgery station 11. The computer 32 connected to themicro-surgery station 11 can also include microsurgery station logic,which can integrate the haptics rendering logic and the graphics logicand provide real-time simulation of open surgery steps of a surgicalprocedure including updating the microsurgical surgical views in realtime in response to user operations performed with a haptic device ofthe micro-surgery station 11. The micro-surgery station logic can alsoinclude an instrument library that includes a plurality of virtualsurgical instruments that can each be selected by a user and displayedby the display system of the micro-surgery station 11. Some examples ofinstruments that can be included in the instrument library for use withthe micro-surgery station 11 are discussed below with respect to themicro-surgery steps of the aneurysm clipping methodology.

Referring now to FIG. 2, one example of a software and hardwarearchitecture for a open surgery station 10 is shown. The architectureincludes interconnected devices and software modules, which areintegrated by a 3D application program interface (API) 39.

FIG. 2 for the open surgery station 10 and FIG. 5 for both the opensurgery station 10 and the microsurgery station 11 include software andhardware for generating image data from scans of actual human anatomy.The volume data pre-processing 40 can receive 2D image data, forexample, generated by an input data source 41, which can be a medicalscanner. The volume data pre-processing 40 can provide 3D models to the3D application program interface 39.

Examples of medical scanners that can be used as an input data source 40for characterizing physical objects include a magnetic resonance imaging(MRI) scanner or a CT scanner, such as those typically used forobtaining medical images. The volume data pre-processing 40 segments andcombines the 2D images to create a virtual 3D volume of the sample thatwas scanned, for example a human head. In an example embodiment formedical images that could be used, for example, for surgical training,the volume data pre-processing 40 creates detailed 3D structures. Thecharacteristics of the various 3D structures will, with the interface toa haptic device 22, present different feel characteristics in thevirtual reality environment, e.g. skin will feel soft and bone hard.Haptics rendering software 44 can monitor and control each haptic device22 including each stylus 27. The haptics rendering software 44 can readthe position and orientation of each haptic device 22, for example astylus 27, or a plurality of styluses 27 for different functions or foruse by separate hands, and computes single or multi-point collisiondetections between a virtual device corresponding to the haptic device22 and objects within the 3D virtual environment. The haptics renderingsoftware 44 can also receive 3D models from the 3D application programinterface 39. For example, single or multi-point collisions with avirtual device and imported 3D isosurfaces can be computed, and thehaptics rendering software can direct a haptic device 22 to generate thecorresponding force feedback. In some examples, each isosurface isassigned different haptic materials, according to certain parameters:stiffness, viscosity, static friction and dynamic friction, as well asdifferent physical properties such as density, mass, thickness, damping,bending, etc. Therefore, the user 12 can feel the different surfaces andtextures of objects and surfaces in the virtual environment.

In a surgical simulation example, the user 12 can feel differentsensations when touching skin, bone, and internal organs, such as thebrain. In a preferred embodiment, the graphics and haptics can be on twoseparate threads, which can be implemented, for example with a dualprocessor computer. The haptics and graphics have their own updateschedule, for example, haptics at 1000 Hz and graphics at about 30 Hz.In that example, the system would synchronize the two consecutivegraphics update after about every 30 haptic updates, and it is withinthe skill of artisans to modify the manner in which haptics and graphicsupdate and synchronize.

Hand tracking is very useful because it allows users to use both handsto interact with the virtual scene. While the user can feel tactilesensations with a hand holding a haptic stylus 27, it is also possibleto use a tracked hand to move the 3D objects, manipulate lights, ordefine planes in the same 3D working volume. Graphics rendering software46 receives 3D models from the 3D application program interface 39.Also, the graphics rendering software 46 receives virtual tool(s)information from the haptics rendering software 44. With the models andother information, the graphics rendering software 46 software generatesand continuously updates, in real time, the stereoscopic 3D display thatis displayed by a display screen 28.

The API 39 can provide a camera node that computes the correctviewer-centered perspective projection on the virtual projection plane.It can properly render both left and right views according to theposition and orientation of the user's head given by the trackingsystem.

Sound rendering 49 can also used to add auditory simulations to avirtual environment through each 3D sound system 24. One example ofsound rendering software is Open Audio Library (OpenAL), which is afreely-available cross-platform 3D audio API that serves as a softwareinterface to audio hardware. OpenAL is can generate arrangements ofsound sources around a listener in a virtual 3D environment. It handlessound-source directivity and distance-related attenuation and Dopplereffects, as well as special effects such as reflection, obstruction,transmission, and reverberation.

Simulation of Aneurysm Clipping

Methods of the present technology include virtual reality simulation ofaneurysm clipping surgical procedures, and can include simulation of oneor more portions of such procedures, or even the entire procedure. Themethods can include, for example, simulation of procedures includingcraniotomy, dural opening, navigation along the Sylvian fissure,clipping of the aneurysm, and flow testing of the patency of the parentvessel. In some examples, the Sylvian fissure can be presented as beingpre-dissected, but can have elastic tissue boundaries. Additionally,flow testing of the patency of the parent vessel can be provided bysuitable virtual instruments, such as a quantitative microvascularultrasonic flowmeter (e.g., Charbel Micro-Flowprobe® of TransonicSystems), or a virtual gamma camera that visualizes a virtual injectionof an indocyanine green (ICG) cyanine dye used for diagnosticfluorescence angiography. A virtual gamma camera can be simulated, forexample, by a grayscale rendering of the blood vessels based on flowintensity.

One example of an aneurysm clipping method that can be performed using ahaptic augmented and virtual reality system of the present technology isshown in FIG. 5. In the illustrated example, the open surgery steps ofaneurysm clipping can be performed by a user located at a open surgerystation 10, and can include burr hole drilling 84, craniotomy 85, anddural opening 86. The microsurgical steps, can be performed by a userlocated at a microsurgery station 11, and can include Sylvian fissuredissection 83, aneurysm clip selection task 90 from clip library 71 andheld in clip holder 72, tissue dissection task 89 around the aneurysmand its parent vessel, aneurysm clip placement and closure on aneurysmneck 91, blood flow testing 92 with ultrasound flow sensor 75, andoptional aneurysm rupture and repair 74.

As discussed above, the haptic augmented and virtual reality system canperform data pre-processing 40 by first receiving patient-specificmedical imaging input data from an input data source 41. The data may beprovided and received in a standard format such as DICOM. The DICOM orother input data received by the can be originally in the form oftwo-dimensional (2D) slices of patient anatomy. During datapre-processing 40, the segment anatomy preprocessing module can convertthe 2D data into 3D format.

For the case of simulated cerebral aneurysm clipping, the 3D outputs ofthe segment anatomy module 130 can include the virtual patient's skull3D volume 131, the dura mater 3D mesh 132, the brain 3D mesh 133, andthe blood vessel 3D mesh 134, including the aneurysm neck and sac andparent artery. These four 3D anatomical outputs for the brain, enclosedwithin a dotted line and numbered together as item 140 in FIG. 5,constitute a suite of pre-processed virtual brain elements and may bereferred to as a virtual patient case. The numeral 140 symbolizes bothan individual patient case and any other such cases that can be storedpermanently in the system to comprise a patient case library.

A user can begin the performance of simulated cerebral aneurysm clippingby first being seated at the open surgery station 10, and becomingfamiliar with the input and interaction devices, including haptic stylus27, which can have a least one input device, such as ON/OFF togglebutton 25, or a pinch attachment 29, as shown in FIG. 6. Pinchattachment 29 can measure the angle between the user's thumb and indexfingers to simulate both discrete or gradual opening and closing of avirtual surgical instrument. Another example of an input device for ahaptic stylus 27 would be a scissors-grip attachment.

1. Selection of a Patient Case and Surgical Planning

Using the graphics user interface (GUI) 43, which can be displayed onscreen 28 and reflected on partially transparent mirror 30 or displayedon an auxiliary tablet computer, the user can select a particular casefrom the patient case library 140.

FIG. 19 shows a simulated radiology scan, particularly DICOM image 200,of a patient displayed on screen 28 and reflected on partiallytransparent mirror 30. From instrument library 120 the user can performthe select instrument task 121, and thus select a surgical marker 55(FIG. 14). The system logic can automatically superimpose an image ofthe surgical marker over the real haptic stylus 27 visible throughpartially transparent mirror 30. Using the haptic stylus 27, the usercan manipulate the co-located virtual marker 55 to mark and measure aplanned craniotomy on the simulated radiology scan 200.

Next, the user can be visually presented with a virtual patient head202, which the user can grasp and rotate into proper position by using ahaptic stylus 27. As shown in FIG. 20, the radiology scan 200 can bedisplayed on the screen, for reference. A clamp 204 can hold the virtualpatient head 202. Using the haptic stylus 27, the user can manipulatethe co-located virtual marker 55 to draw an outline of the intendedcraniotomy on the skin of the virtual patient head 202. One example ofpossible craniotomy location is a pterional (frontotemporal) craniotomy.The user can inform the system of completion of the craniotomy markingtask through a system input device (e.g., GUI, foot pedal, auxiliarytablet computer, etc.).

FIG. 21 illustrates a view of the patient head 202, with the bone flapremoved to allow planning of surgical access on the open surgerystation. In some examples, the clamp 204 can be removed, to allow forverification of whether the surgical access is appropriate by alteringthe user views in the head and hand tracked system.

The output from the open surgery station that results from thecraniotomy simulation can be used as a surgical plan. This surgical plancan be transferred to the operating room (OR) image guided system byappropriate coordinate transformation and overlaid on the image guidedsystem to assist in actual surgery execution of the plan. Standard imageguided systems in the OR can employ an optical tracking system, whereasthe open surgery simulator and/or microsurgery simulator may employelectromagnetic tracking, or other types of tracking, such as optical,inertial or physical tracking. The image guided system in the OR and thesurgical simulation plan in the open or microsurgery stations canrepresent the same relative anatomical structure information scaleddifferently.

2. Burr Hole Drilling (Task 84).

The user can select a burr tool 64 (FIG. 11) from instrument library120. The system can superimpose an image of the tool over the realhaptic stylus 27 visible through partially transparent mirror 30. Theuser handle the virtual burr tool 64 by manipulating a haptic stylus 27,and can turn on the virtual burr tool by activating an input device suchas a foot pedal 34 or the haptic stylus input device 25. The user canproceed to user task make burr holes 84, and can drill a plurality ofburr holes through the simulated cranium, avoiding penetration of thesimulated dura mater. Simultaneously in real time, the system logic canperform system task 110 and continuously update the skull geometry usingskull 3D volume 131. The system's volume haptics rendering module 112calculates the force that the user is exerting on the tool toprogressively remove the bone volume and outputs the force result to thehaptic stylus 27. The system's volume graphics rendering module 113calculates the progressive visual disappearance of bone volume andoutputs the result to the stereoscopic display 28. The user can informthe system of task completion, and in some examples, the system cancalculate and record a score for the task, which can be displayed at anytime.

3. Craniotomy (Task 85).

The user can select a virtual craniotome 73, as illustrated in FIG. 9,from instrument library 120. The system logic superimposes an image ofthe virtual craniotome 73 over the real haptic stylus 27. The userhandles the virtual craniotome 73, at user task 65, by manipulating ahaptic stylus 27, and can turn on the virtual craniotome 73 byactivating an input device such as a foot pedal 34 or the haptic stylusinput device 25. The user can proceed to connect the previously drilledburr holes by performing a craniotomy at user task 85, which can includecutting the cranial bone volume between the holes so as to create acraniotomy bone flap using for example a virtual reciprocating saw 56(FIG. 17). Simultaneously in real time, the system logic progressivelyupdates the skull geometry at system task 110 using the skull 3D volume131. The volume haptics rendering module 112 calculates the force thatthe user is exerting on the tool to progressively remove the bone volumeand outputs the force result to the haptic stylus 27. The volumegraphics rendering module 113 calculates the progressive visualdisappearance of bone volume and outputs the result to the display 28.The user can inform the system of task completion, and in some examples,the system can calculate and record a score for the task, which can bedisplayed at any time.

4. Opening of Dura Mater (Task 86).

The user selects microscissors 57, as illustrated in FIG. 18, frominstrument library 120. The system logic superimposes an image of thevirtual microscissors 57 over the real haptic stylus 27. The userhandles the microscissors, user task 66, and can opens and close thevirtual microscissors 57 by the haptic stylus input device 25. The usercan proceed to cut an opening in the simulated dura mater according toprescribed surgical protocols, user task 86. Simultaneously in realtime, the system logic progressively updates the dura mater 3D mesh 132for the emerging dural opening, system task 111, by using the system'sposition-based dynamics computation module 116. Based uponposition-based dynamics the system's polygonal haptics rendering module44 calculates the force that the user is exerting on the tool toprogressively cut the dura and outputs the force result to the hapticstylus 27. The system's polygonal graphics rendering module 46calculates the progressive visualized cutting of the dura and outputsthe result to the display 28. The user can inform the system of taskcompletion, and in some examples, the system can calculate and record ascore for the task, which can be displayed at any time.

At the completion of the dural opening, display of the virtual patienthead with craniotomy and dural opening can be transferred from the opensurgery station 10 to the microsurgery station 11. In examples wheredifferent computers are used for the open surgery station 10 and themicrosurgery station 11, data for the virtual patient head can betransferred from the computer at the open surgery station 10 to thecomputer at the microsurgery station 11. This transfer may be set tooccur automatically upon signaled completion of the dural opening, or itmay be separately requested by the user. The user can also physicallymove from the open surgery station 10 to the microsurgery station 11.

5. Sylvian Fissure Dissection with Artificial Blood Flow ModelingOutside the Vessels (Task 83).

The Sylvian fissure (lateral sulcus), which divides the brain's frontallobe from the temporal lobe, is the major anatomical structure that mustbe opened to access many aneurysms of the anterior circulation, forexample on the middle cerebral artery. The fissure can be accessed by apterional (frontotemporal) craniotomy, as described above, but thedescription here and the claims below apply to any placement ofcraniotomy (e.g., retrosigmoid) and any open surgical access method toreach a cerebral aneurysm.

To begin a virtual Sylvian fissure dissection, user task 83, the usercan be seated at the microsurgery station 11, which can include abinocular surgical eyepiece 31, foot pedals 34, and two haptic devicesfor bimanual surgical technique, with each device having a haptic stylus27, as shown in FIG. 4. The user will typically select two or morevirtual surgical tools from instrument library 120. These may include,for example, for the left hand a virtual suction tip 69, illustrated inFIG. 10, and for the right or dominant hand a virtual dissection toolsuch as an virtual arachnoid knife 70, micro scissors 57, illustrated inFIG. 18, or bipolar electrocautery forceps 68, illustrated in FIG. 13,cauterizer (FIG. 12) with a possibility of changing instruments at anytime. The system logic superimposes an image of the virtual suction tip69 (FIG. 10) and of the virtual dissection tool over the left-hand andright-hand haptic styluses, respectively. The action of the instrumentsmay be activated by a foot pedal 34 or by a haptic stylus input device25. With the right or dominant hand the user handles the virtualdissection tool such as the bipolar forceps, user task 68, and cuts thetissues within the Sylvian fissure (for example) that adhere to andconnect the frontal and temporal lobes, so as to open the Sylvianfissure, user task 83. With the left hand the user handles the suctiontip, user task 69, and activates the suction so as to absorb anysimulated blood flow in the fissure outside the blood vessels, user task123, which originates from the dissection of the virtual fissure tissuesand is not already coagulated by the virtual bipolar forceps.Simultaneously in real time, the system's artificial (not physics-based)blood flow rendering module 137 progressively updates the appearance andamount of simulated blood flow outside the vessels and its absorption bythe suction tool, system task 123, and outputs the result to the display28. Furthermore, the system logic progressively updates the brain 3Dmesh 133 so as to deform the brain for the emerging Sylvian fissureopening, system task 114, by using the system's position-based dynamicscomputation module 116. Based upon position-based dynamics the system'spolygonal haptics rendering module 44 calculates the force that the useris exerting on the dissection tool to cut the tissues that connect thefrontal lobe and temporal lobes and outputs the force result to thehaptic stylus 27. The system's polygonal graphics rendering module 46calculates the progressive visualized cutting of the tissues in theSylvian fissure and outputs the result to the display 28. The dissectiontask for the Sylvian fissure is considered complete when the aneurysm ofinterest becomes visible and accessible at the bottom of the fissure.The user can inform the system of task completion, and in some examples,the system can calculate and record a score for the task, which can bedisplayed at any time.

6. Brain Retraction (Task 87).

In past medical practice mechanical brain retraction was often performedin the early phases of opening the Sylvian fissure, and this can also besimulated by the haptic and virtual reality system using the haptic andvirtual reality station 10 as described here. However, several currentmedical guidelines recommend creation of a wide opening of the Sylvianfissure by drainage of cerebrospinal fluid and dissection of tissues,without mechanical brain retraction. After the fissure has been opened,a malleable metal brain spatula can be applied to hold (not to retract)one of the lobes of the brain, such as the frontal or temporal lobe, toprovide a better view of the aneurysm. The user selects a retractor inthe form of a virtual brain spatula 67 from instrument library 120. Thesystem logic superimposes an image of the tool over the real hapticstylus 27. The user handles the virtual brain retractor, user task 67,and proceeds to place the retractor against one of the exposed lobes ofthe virtual brain so as to hold the dissected surgical line of accessopen for the dissection of tissues around the aneurysm and clipping ofthe aneurysm. Simultaneously in real time, the system logicprogressively updates the brain 3D mesh 133 for the retracted brain,system task 114, by using the system's position-based dynamicscomputation module 116. Based upon position-based dynamics the system'spolygonal haptics rendering module 44 calculates the force that the useris exerting on the retractor to hold the brain in position, and outputsthe force result to the haptic stylus 27. The system's polygonalgraphics rendering module 46 calculates the progressive visualizedmovement or deformation of the brain and outputs the result to thedisplay 28. The user informs the system of task completion and receivesa score.

7. Sylvian Fissure Dissection with Artificial Blood Flow ModelingOutside the Vessels (Task 83).

The Sylvian fissure (lateral sulcus), which divides the brain's frontallobe from the temporal lobe, is the major anatomical structure that mustbe opened to access many aneurysms of the anterior circulation, forexample on the middle cerebral artery. The fissure can be accessed by apterional (frontotemporal) craniotomy, as described above, but thedescription here and the claims below apply to any placement ofcraniotomy (e.g., retrosigmoid) and any open surgical access method toreach a cerebral aneurysm.

8. Dissection Around Aneurysm (Task 89).

The Sylvian fissure dissection task 83 concludes when a sufficientlywide opening and pathway to the parent vessel and aneurysm has beencreated. The next surgical step is to dissect carefully around theaneurysm parent vessel, neck, and dome or sac, without unnecessarilysacrificing nearby micro-vessels, so as to prepare an open space inwhich an aneurysm clip can be placed without inadvertently clippingother vessels and without unduly narrowing the parent vessel. In livesurgery this task is continuous with the Sylvian fissure dissection, andthe surgeon uses the same tools, typically a suction tip, user task 69,and a knife, microscissors, or bipolar forceps, user task 68. Similarly,the system functions are the same as in the Sylvian fissure dissection.The system logic progressively updates the brain 3D mesh 133 to show thedeformation of vessels, system task 115, that results from thedissection around the aneurysm. Based upon position-based dynamics thesystem's polygonal haptics rendering module 44 calculates the force thatthe user is exerting on the dissection tool to cut or manipulate thetissues and blood vessels, and outputs the force result to the hapticstylus 27. The system's polygonal graphics rendering module 46calculates the progressive visualized dissection around the aneurysm andoutputs the result to the display 28.

9. Choosing of an Aneurysm Clip and Closing of Clip on Aneurysm Neck(Tasks 90 and 91).

Aneurysm clip selection is a crucial part of the operation because thereare many different shapes, sizes, and positions of aneurysms and acorresponding wide variety of clips of different sizes, shapes(straight, curved), and designs (e.g., fenestrated clips that go aroundone vessel to clip another). Based on a direct line of sight of thevirtual aneurysm on the simulator as well as on patient-specificcerebral angiograms stored in the patient case library 140, the userperforms the aneurysm clip selection, user task 90, to select anappropriate virtual aneurysm clip 100 from clip library 71. The systemlogic superimposes an image of an aneurysm clip holder 72 (see FIG. 72)together with clip 100 (see FIG. 7) over the real haptic stylus 27. Theuser handles the clip holder, user task 72, and applies differentialfinger pressure to a haptic stylus input device such as ON/OFF togglebutton 25, or a pinch attachment 29 (FIG. 6) to hold the clip or toclose and release the clip. After taking an initial measurement of bloodflow in the parent artery by means of a virtual perivasular flow sensor(see below), the user proceeds to place the clip snugly around thevirtual aneurysm neck and to close it on the neck so as to seal off thepulsatile blood flow from the parent artery into the aneurysm sac, thusrendering the aneurysm clinically harmless. Simultaneously in real time,the system logic progressively updates the brain 3D mesh 133 to show thedeformation of vessels, system task 115, that results from placing theclip around the aneurysm neck. Based upon position-based dynamics thesystem's polygonal haptics rendering module 44 calculates the force thatthe user is exerting on the virtual clip holder 72 (FIG. 8) to deformthe blood vessel and aneurysm, and outputs the force result to thehaptic stylus 27. The system's polygonal graphics rendering module 46calculates the progressive visualized closing of the clip around theaneurysm and outputs the result to the display 28. The user informs thesystem of task completion, and the score for the aneurysm clipping isdetermined by the next step, testing of the parent artery blood flow.

10. Flow Testing of Parent Artery Before and after Aneurysm ClipPlacement (Task 92).

Success in aneurysm clipping is achieved by (a) fully clipping theaneurysm neck so that there is no remaining pulsatile blood flow throughthe neck into the aneurysm sac; (b) avoiding entrapment of other nearbysmall perforating arteries within the grasp of the clip; and (c)avoiding clip placement too close to the parent artery, which wouldreduce its inner diameter and therefore its blood flow. While thesuccess of the first two tasks is determined visually, success of thethird task, preserving blood flow in the parent artery, is determined bytesting the flow in the parent artery before and after clip placement. Astandard real-life method is to use an ultrasonic perivascular flowsensor, placed around the parent artery, that relies on the principle oftransit-time ultrasound volume flow measurement and outputs blood flowin units of mL/min, but other methods of quantitative flow measurementare included. The present haptic augmented and virtual reality systemsimulates the change of parent artery blood flow after placement of avirtual aneurysm clip, together with the measurement of this change by avirtual flow probe, on the basis of the clip's final position and aprecalculated table of vessel diameters, blood pressures, and flowvalues, system task 144, rather than by a fully realistic computationalfluid dynamics simulation of the blood flow and of the operation of thevirtual ultrasonic probe.

To make a quantitative volumetric measurement of the virtual blood flowin the parent artery before and after aneurysm clipping, the userselects the ultrasonic perivascular flow sensor 75 from instrumentlibrary 120. The system logic superimposes an image of the virtual flowsensor over the real haptic stylus 27. The user handles the flow sensor,user task 75, and proceeds to place the C-shaped head of the sensoraround one or more sections of the proximal parent artery and/or itsdistal branches. Simultaneously in real time, the system logicprogressively updates the brain 3D mesh 133, which includes the vesselsand the aneurysm, to reflect the pressure of the sensor on the parentartery and the artery's consequent deformation, system task 115, byusing the system's position-based dynamics computation module 116. Basedupon position-based dynamics the system's polygonal haptics renderingmodule 44 calculates the force that the user is exerting on the sensorwhile measuring the blood flow and outputs the force result to thehaptic stylus 27. The system's polygonal graphics rendering module 46calculates the progressive visualized deformation of the parent arteryand outputs the result to the display 28. The user performs the flowmeasurement on the parent artery before and after clipping its aneurysm.The system calculates these two volumetric flow values in mL/min, systemtask 144, and outputs these values as well as the difference to display28. The user either accepts the result if the parent artery blood flowis not reduced beyond a predetermined percentage of its pre-clippingvalue (e.g., 25 percent maximum reduction), in which case the simulationexercise is completed and the user receives an aneurysm clipping scoreand a comprehensive score. Otherwise, the user can reposition the clipand retest the blood flow, or can select a new clip, task 90, fromlibrary 71 and repeat the exercise.

As an additional means of virtual blood flow testing, the system cansimulate the intraarterial injection of an indocyanine green (ICG)contrast agent used for diagnostic fluorescence angiography, wherein theflow of the contrast agent inside the vessels is visualized by a virtualgamma camera. The simulator user requests the injection of the ICGthrough the system's graphic user interface, which counts as the user'sperformance of task 92, flow testing of parent artery after clipplacement. The system then performs task 117, render the blood flow bymeans of smooth particle hydrodynamics, which is a real-time(interactive) physics-based approximation method, but not a fullyaccurate (and time consuming) computational fluid dynamic simulation.The visualized contrast injection of task 117 is output to the graphicdisplay 28. The virtual ICG injection visualizes the blood flow indistal branches the parent artery downstream from the aneurysm neck andclip, but it can also visualize blood flow in smaller perforatingarteries near the parent artery to ensure that they have not beenaccidentally included in the grasp of the virtual aneurysm clip.Perforating arteries below the resolution of current medical imagingdevices (cf. input source 44) can be modeled manually and added to theblood vessel 3D mesh 134.

11. Optional Aneurysm Rupture Simulation (Task 74).

An aneurysm may rupture at any time but particularly during thedissection around the aneurysm, user task 89, or the placing of theaneurysm clip, user task 91. The system can be programmed to simulate ananeurysm rupture as a random event to test user emergency response, orto simulate a rupture in response to a user surgical error. When arupture is simulated, system task 74, the system deforms the aneurysmsac, system task 115, then uses position-based dynamics, system task116, and polygonal graphics rendering, system task 46, to output thevisual result to display 28. When an aneurysm ruptures, the system alsorenders artificial blood flow into the subarachnoid space, system task137, and outputs the visual result to display 28

The simulation method can include evaluation of a user's performance. Auser can be scored based on patient head positioning, craniotomypositioning and cutting, dural opening, aneurysm clip selection,left-handed and right-handed clip manipulation, repositioning ofmisplaced clips, use of suction tip and bipolar electrocautery, totalattempts at clip placement, and responses to errors, including aneurysmrupture, incomplete clipping, clips too distant from parent vessel,unacceptable narrowing of parent vessel as determined by flow testing,etc. The simulator can record a score on each of the surgical steps orerror recovery strategies, with appropriate weighting to yield anoverall comprehensive score.

From the foregoing, it will be appreciated that although specificexamples have been described herein for purposes of illustration,various modifications may be made without deviating from the spirit orscope of this disclosure. For example, views to be displayed on themicro surgery and open surgery stations can be instantiated usingvarious systems, including HTC Vive, Oculus Rift (from Facebook) orMicrosoft Hololens, and different sensor combinations such as LeapMotion sensor, as an alternative to the views shown and discussed above.These can be obtained by varying the views in a head and hand trackedsystem by using different modes of tracking. The illustrated apparatusshows one tracking mode combination but it can be instantiated to othertracking mode combination to achieve the same end user desired effect.It is therefore intended that the foregoing detailed description beregarded as illustrative rather than limiting, and that it be understoodthat it is the following claims, including all equivalents, that areintended to particularly point out and distinctly claim the claimedsubject matter.

What is claimed is:
 1. A method of performing a simulated surgical procedure that includes open surgery steps and microsurgery steps using a haptic augmented and virtual reality system, comprising: performing at least one open surgery step of a simulated surgical procedure, the a least open surgery step employing: a first haptic device comprising a hand-held stylus and driven by first haptics rendering logic, wherein the first haptic device tracks a user's hand movements and provides force feedback to the user, a first display system driven by first graphics logic, wherein the first display system comprises a display screen and a head tracking system, and provides a dynamic user-centered perspective of open surgical views of a portion of a virtual patient's anatomy and at least a first virtual surgical instrument, wherein the at least first virtual instrument is either visually superimposed over or visually correlated in space with the hand-held stylus of the haptic device, permitting the user to see the at least first virtual instrument, and moves as the stylus moves based on data received from the first haptic device, and open surgery logic that integrates the first haptics rendering logic and the first graphics logic and provides real-time simulation of the open surgery steps of the surgical procedure, including updating the open surgical views in real time in response to user operations performed with the first haptic device and according to the position and orientation of the user's head given by the head tracking system, and performing at least one micro-surgery step of a simulated procedure, the at least one micro-surgery step employing: a second haptic device driven by second haptics rendering logic, wherein the second haptic device tracks the user's hand movements and provides force feedback to the user, a second display system driven by second graphics logic, wherein the second display system comprises a surgical microscope eyepiece and display screens configured to allow the user to acquire depth perception, and provides microsurgical views of a portion of the virtual patient's anatomy and at least a second virtual surgical instrument whose position and/or orientation is simulated based on data received from the second haptic device or other input; wherein the at least second virtual instrument or the virtual hand or both are visually seen with respect to the fixed user centered perspective of the hand holding the stylus of the second haptic device, and moves as the stylus moves based on data received from either the second haptic device or other input, and microsurgery logic that integrates the second haptics rendering logic and the second graphics logic and provides real-time simulation of the microsurgery steps of the surgical procedure including updating the microsurgical surgical views in real time in response to user operations performed with the second haptic device; and transferring data between the open surgery logic and the microsurgery logic.
 2. The method of claim 1, wherein the simulated surgical procedure is an aneurysm clipping procedure on a simulated patient head.
 3. The method of claim 2, wherein: performing the at least one open surgery step of a simulated surgical procedure comprises: drilling a plurality of burr holes that define a bone flap location in the simulated patient head; performing a craniotomy; performing dural opening; and performing the at least one micro-surgery step of a simulated surgical procedure comprises: performing Sylvian fissure dissection; performing tissue dissection around an aneurysm of the simulated patient head; placing an aneurysm clip and closing the aneurysm clip on a neck of the aneurysm.
 4. The method of claim 2, wherein performing the at least one open surgery step of a simulated surgical procedure comprises performing burr hole drilling on the simulated patient head including steps of: (a) superimposing an image of a burr tool over the first haptic device using the first display system, the burr tool being selected by the user from an instrument library that includes a plurality of virtual surgical instruments that can each be selected by the user; and (b) drilling a plurality of burr holes that define a bone flap location in the patient anatomy, wherein a volume haptics rendering module of the system calculates a force that the user is exerting on the tool to progressively remove bone volume and outputs the calculated force to the hand-held stylus, and a volume graphics rendering module of the system calculates progressive visual disappearance of bone volume and outputs the calculated progressive visual disappearance of bone volume to the first display system.
 5. The method of claim 4, wherein performing the at least one open surgery step of a simulated surgical procedure further comprises performing a craniotomy on the simulated patient head including steps of: (a) superimposing an image of a craniotome over the first haptic device using the first display system, the craniotome being selected by the user from the instrument library; and (b) performing the craniotomy, wherein the volume haptics rendering module calculates force that the user is exerting on the tool to progressively remove bone volume and outputs the calculated force to the hand-held stylus, and the volume graphics rendering module calculates progressive visual disappearance of bone volume and outputs the progressive visual disappearance of bone volume to the first display system.
 6. The method of claim 5, wherein performing the at least one open surgery step of a simulated surgical procedure further comprises performing dural opening on the simulated patient head including steps of: (a) superimposing an image of a craniotome over the first haptic device using the first display system, the craniotome being selected by the user from the instrument library; and (b) cutting an opening in the simulated dura mater, wherein the volume haptics rendering module calculates force that the user is exerting on the tool to progressively cut dura and outputs the calculated force to the hand-held stylus, and the volume graphics rendering module calculates progressive visualized cutting of the dura and outputs the calculated progressive visualized cutting of the dura to the first display system.
 7. The method of claim 6, further comprising a step of transferring display of the simulated patient head with craniotomy and dural opening from the open station to the microsurgery station.
 8. The method of claim 2, wherein performing the at least one micro-surgery step of a simulated surgical procedure comprises performing Sylvian fissure dissection on the simulated patient head including steps of: (a) displaying images of two or more virtual surgical tools, including a dissection tool, on the second display system, the tools selected by the user from an instrument library that includes a plurality of virtual surgical instruments that can each be selected by the user; and (b) cutting tissues of the simulated patient head that adhere to and connect frontal and temporal lobes, so as to open the Sylvian fissure, wherein a haptics rendering module of the system calculates a force that the user is exerting on the dissection tool to cut the tissues and outputs the calculated force to the second haptic device.
 9. The method of claim 8, wherein performing the at least one micro-surgery step of a simulated surgical procedure further comprises performing tissue dissection around an aneurysm of the simulated patient head including a step of: cutting tissues and blood vessels of the simulated patient head to prepare an open space in which an aneurysm clip can be placed, wherein the haptics rendering module of the system calculates a force that the user is exerting on the dissection tool and outputs the calculated force to the second haptic device.
 10. The method of claim 9, wherein performing the at least one micro-surgery step of a simulated surgical procedure further comprises placing an aneurysm clip including steps of: (a) displaying an image of a selected aneurysm clip on the second display system, the aneurysm clip being selected by the user from a clip library of the system; and (b) placing the aneurysm clip, in which the haptics rendering module calculates force that the user is exerting on the virtual clip holder and outputs the calculated force to the second haptic device, and the graphics rendering module calculates progressive visualized closing of the aneurysm clip around the aneurysm and outputs the calculated progressive visualized closing to the second display system.
 11. The method of claim 1, wherein performing at least one open surgery step of a simulated surgical procedure comprises selecting a virtual surgical instrument from an instrument library that includes a plurality of virtual surgical instruments that can each be selected by a user and displayed by the first display system.
 12. The method of claim 11, wherein the virtual surgical instruments include a burr tool, a craniotome, and micro-scissors.
 13. The method of claim 1, wherein performing at least one microsurgery step of a simulated surgical procedure comprises selecting a virtual surgical instrument from an instrument library that includes a plurality of virtual surgical instruments that can each be selected by a user and displayed by the second display system.
 14. The method of claim 13, wherein the virtual surgical instruments include bipolar forceps, an arachnoid knife, a brain retractor, a suction tip, a clip holder, an ultrasound blood flow probe, a dissection tool, and micro-scissors. 